PEDIATRIC GYNECOLOGY AND GYNECOLOGICAL DISORDERS IN CHILDREN AND ADOLESCENTS

1. PEDIATRIC GYNECOLOGYAND GYNECOLOGICAL DISORDERS IN CHILDRENAND ADOLESCENTS Rukset Attar, MD, PhD Obstetrics and Gynecology Department

2. Pediatric & AdolescentGynecology • Gynecologic care begins in the delivery room, with inspection of the external genitalia during routine newborn examination. • Evaluation of the external genitalia continues through routine well-child examinations, permitting early detection of infections, labial adhesions, congenital anomalies, and even genital tumors. • A complete gynecologic examination is indicated when a child has symptoms or signs of a genital disorder

3. CommonGynecologicDisorders • Newborn Infants • During the first few weeks of life, residual maternal sex hormones may produce physiologic effects on the newborn • Breast budding occurs in nearly all female infants born at term. In some cases, breast enlargement is marked, and there may be fluid discharge from the nipples - No treatment is indicated. • The labia majora are bulbous, and the labia minora are thick and protruding • Vaginal bleeding may occur • Vaginal discharge is common, composed mainly of cervical mucus and exfoliated vaginal cells.

4. CommonGynecologicDisorders • Congenital Anomalies of the Female Genital Tract • Anomalies of the Vulva & Labia • Anomalies of Clitoris • Anomalies of the Hymen • Anomalies of the Uterus • Anomalies of the Ovaries • Anomalies of the Urethra and Anus

5. CommonGynecologicDisorders • LabialAdhesions • %1.4 • estrogendeficiencyandinflammation • applyingestrogencreamtothefinethinraphetwice a dayfor 2 weeksfollowedbyoncedailyapplicationfor 2 weeks. • parentsareaskedtorepeatthecourse of treatment in 6-month to 1-year intervalsifrecurrenceoccurs.

6. CommonGynecologicDisorders • estrogen cream can be systemically absorbed, parents may notice transient breast development • Forceful manual separation is not advised • as this is often painful and traumatic to the child • recurrence is much more common. • Surgical separation is rarely justified and only applicable if urinary problems result and estrogen therapy has failed.

7. CommonGynecologicDisorders • Imperforate Hymen • A mucocolpos or hematocolpos can develop • is apparent as a bulging thin membrane at the introitus with the Valsalva maneuver or crying • Surgical incision

8. CommonGynecologicDisorders • Vulvitis • vulvar discomfort or itching • The first step is to take a careful history in regards to any possible irritants • the level of hygiene, • urinary incontinence, • frequency of diaper changes, and • bathing habits. • Diaper dermatitis

9. CommonGynecologicDisorders • Common organisms causing prepubertal vulvitis are • Candida • usu. under the age of 2 • may follow a course of antibiotics in the infant • underlying factors such as juvenile onset diabetes or immunosuppression • antifungal creams such as clotrimazole, miconazole, or butaconazole applied twice a day to the affected area for 10 to 14 days or until rash is cleared

10. CommonGynecologicDisorders • Pinworms (Enterobius vermicularis) • Diagnosis is made by • inspecting at night with a flashlight to observe worms exiting the anus • a morning inspection with "Scotch tape" to the anal region can identify the eggs. • Treatment consists of mebendazole (Vermox) 100 mg orally once and repeated in 1 week. • It is advised to treat the entire family to prevent reinfection • Group A β-hemolytic streptococcus • appropriate antibiotic for 2 weeks and occasionally for longer periods of time (up to 4 weeks)

11. CommonGynecologicDisorders • Contact or allergic vulvitis • Treatment may consist of removing the irritant • if itching is severe • providing an oral medication, such as hydroxyzine hydrochloride (Atarax), 2 mg/kg/d divided into four doses, • application of topical hydrocortisone cream 2.5% twice a day for a week and then discontinuing.

12. CommonGynecologicDisorders • Lichen Sclerosus • itching, irritation, soreness, bleeding, and dysuria. • The vulva is characteristically white, atrophic, with parchmentlike skin and occasionally evidence of subepithelial hemorrhages, excoriations, fissures, and inflammation • Treatment consists of clobetasol (Temovate) cream 0.05% applied nightly to the affected area for 6 weeks. • Follow-up should be scheduled at that time and if there is significant improvement the dose is tapered progressively until it is being used only one time weekly at bedtime.

13. CommonGynecologicDisorders • Nonspecific Vulvovaginitis • is the most common gynecological disorder of prepubertal girls (accounts for over 50% of visits) • Poor hygiene practices at home or daycare program • Inadequate front-to-back wiping • Smaller labia minora, which are less protective of the vestibule, with a short distance from the anus to vagina • Vulvovaginal epithelium that is not well estrogenized and thus thinner and more prone to irritation • Foreign body such as toilet paper, small toys, or pieces of cloth, which may be inadvertently inserted in the vagina by the child • Chemical irritants such as bubble baths, shampoos, or bath oils, and certain deodorant soaps • Dermatologic conditions such as eczema and seborrhea • Chronic disease and altered immune status • Sexual abuse

14. CommonGynecologicDisorders • The pathogenesis of vulvovaginitis is not well defined • may be associated with an alteration of the vaginal flora with an overgrowth of fecal aerobes or an overabundance of anaerobes contributing to the symptoms of odor and discharge. • Cultures performed indicate a variety of organisms considered normal vaginal flora such as diphtheroids, enterococci, coliforms, and lactobacillus. • Escherichia coli is often found on vaginal culture, suggesting poor hygiene; contamination with bowel flora may contribute to the problem.

15. CommonGynecologicDisorders • Infectious Vulvovaginitis • Hemophilus influenzae, Staphylococcus aureus, group A β-hemolytic streptococci, and Streptococcus pneumoniae causing a yellowish to greenish purulent vaginal discharge (S. pneumoniae infection and group (amoxicillin 40 mg/kg divided three times a day for 10 days) • Shigella flexneri, an enteric pathogen, can cause a mucopurulent, sometimes bloody discharge following an episode of diarrhea in some young girls(trimethoprim (TMP)-sulfamethoxazole (Bactrim) 6 to 10 mg/kg/d TMP by mouth, divided every 12 hours. Treatment may require more than 10 to 14 days of medication.)

16. CommonGynecologicDisorders • Physiologic Discharge • resulting from maternal estrogen exposure in utero • may appear as clear mucous, whitish in color or clear • On occasion, a bloody discharge is noted and results from exposure to maternal estrogens in utero, causing transient endometrial shedding. • This will most often resolve within a few hours to days.

17. CommonGynecologicDisorders • Condyloma Acuminata • in children less than 2 years of age, the mode of transmission is vertical from mother to child during childbirth. • After age 2, sexual abuse is a primary concern in children presenting with condylomatous lesions (in approximately one third of cases)

18. CommonGynecologicDisorders • treatment • trichloroacetic acid • podophyllin • cryotherapy • CO2 laser vaporization therapy • more recently the advent of imiquimod cream (Aldara), an immune response modifier supplied in a cream base, has eased and revolutionized therapy for external genital warts (A thin layer of cream is applied to the wart(s) at bedtime and left on for 6 to 10 hours, after which it is washed off. Therapy is for 3 days a week (i.e., Monday, Wednesday, and Friday) and continued until the warts are completely gone, or up to 16 week )

19. CommonGynecologicDisorders • Urethral Prolapse • usually presents with unexplained bleeding, often thought to be coming from the vagina. • The child experiences no pain and has no recent history of vulvar trauma. • On physical examination a bright red, friable annular mass is noted just above the hymen surrounding the urethral opening • Treatment consists of estrogen cream to the area nightly for 1 to 2 weeks.

20. CommonGynecologicDisorders • Foreign Bodies • The vaginal discharge is often dark brownish in color • occurs daily, requiring the use of a panty liner by the child. • The discharge is often malodorous

21. CommonGynecologicDisorders • Sexual Abuse • Genital infection with Neisseria gonorrhoeae is associated with a purulent thick yellow discharge along with vulvar erythema and edema. • Chlamydia trachomatis may present with vulvovaginitis, pruritis, and discharge. Infants born to mothers with chlamydia may carry the organism for up to 18 months

22. CommonGynecologicDisorders • Anomalies of sexual development and puberty • Vaginal Bleeding • Bleeding disorders • Juvenile Pregnancy

23. Diagnosis • History • Physical examination • Vaginoscopy • Specimen collection

24. Collection of Specimens • Vaginal cultures are easily collected by a technique described by Pokorny using a catheter within a catheter. A 4-inch segment of the tip of a no. 12 red rubber catheter is placed over the hub end of a butterfly catheter attached to a 1-mL tuberculin syringe . Sterile normal saline (0.05 to 1 mL) is instilled slowly and aspirated back to acquire fluid • Collection of material to evaluate for gonorrhea may be collected by swabbing visible discharge on the perineum or in a similar manner as with chlamydia. • Cultures for chlamydia must include material taken directly from the mucosal surface using a saline-moistened calcium alginate swab (male urethral swab). The swab is inserted into the vagina as the child coughs, which makes the hymen gape open and serves as a distraction.

25. Radiological tests may be performed in those children who are unable to cooperate or have specific problems, such as suspicion of an abdominal mass, abdominal pain, or precocious puberty. • Pelvic ultrasound • computed tomography • magnetic resonance imaging (MRI) scan